Salvage surgery after induction chemotherapy with paclitaxel/cisplatin and primary radiotherapy for advanced laryngeal and hypopharyngeal carcinomas.

Induction chemotherapy followed by primary radiotherapy in responders is considered an alternative to surgery for advanced cancer of the larynx and hypopharynx (LHC). Comparison of therapeutic approaches is challenging and must respect oncological and functional outcome as well as quality of life during and after treatment. One aspect of primary radiochemotherapy is the option of salvage surgery in case of residual tumor. The outcome after salvage surgery following new organ-preserving strategies has to be examined. All patients undergoing induction chemotherapy with paclitaxel and cisplatin followed by radiotherapy from 01/96 to 07/05 were included. Salvage surgery was performed either for local recurrence or suspected persistent nodal disease. Complete tumor removal, perioperative morbidity, and overall survival were analyzed in a retrospective study. 28 out of 134 patients underwent salvage surgery after primary treatment with induction chemotherapy and radiotherapy for advanced LHC. 15 patients had laryngectomy (LE) with neck dissection (ND), while 1 patient had lasersurgical partial laryngeal resection with ND for local recurrences. Twelve patients had salvage ND for suspicion of persistent lymph node metastases. 73% of LE patients had major postoperative problems such as pharyngocutaneous fistulas. In 56% of the cases, tumor removal turned out to be microscopically incomplete. Eight out of 12 patients who underwent salvage ND because of suspicious lymph nodes (66%) were free of vital tumor. When metastatic disease was present in the neck (4/12), recurrences occurred in 75% during postoperative follow-up. Only 2 out of 20 patients undergoing surgery for histologically proven recurrence after radiochemotherapy (10%) are actually tumor-free and alive after a mean observation time of 43.9 months. Salvage surgery for local recurrence is associated with high morbidity and poor oncological and functional outcome. ND for suspicious persistent nodal disease after radiochemotherapy can be an over-treatment. In our patients, it was burdened with cervical recurrences and distant metastases in presence of histologically confirmed lymph node metastases. In the light of our results, unfavourable outcome after salvage surgery must be pointed out when initially informing patients about different therapeutic options for advanced LHC.

Preictal SPECT in temporal lobe epilepsy: regional cerebral blood flow is increased prior to electroencephalography-seizure onset.

UNLABELLED: Peri-ictal SPECT provides unique information on the dynamic changes in regional cerebral blood flow (rCBF) that occur during seizure evolution and, thus, could be useful in clarifying the poorly understood interplay of the interictal and ictal states in human focal epilepsy. The regional hyperperfusion observed on ictal SPECT is generally believed to be a consequence of electrical seizure activity. However, recent studies using invasive long-term cortical CBF monitoring have demonstrated that rCBF changes occur up to 20 min prior to ictal electroencephalography (EEG) onset. Because of apparent technical difficulties, no preictal SPECT studies have been reported so far. Therefore, we present our results on two patients with temporal lobe epilepsy in whom preictal SPECT scans were performed fortuitously under continuous video-EEG monitoring control. METHODS: Technetium-99m-hexamethyl propyleneamine oxime was injected 11 min (Patient 1) and 12 min (Patient 2) before clinical and EEG seizure onset, as documented from simultaneous video-EEG monitoring in two patients with temporal lobe epilepsy. We obtained accurate anatomical reference of CBF changes visible on SPECT by a special coregistration technique of MRI and SPECT. RESULTS: Whereas interictal SPECT showed a hypoperfusion of the temporal lobe ipsilateral to the seizure focus, on preictal SPECT, a significant increase in rCBF in the epileptic temporal lobe could be observed. These rCBF changes were not accompanied by any significant changes of the ongoing EEG. CONCLUSION: Our study provides evidence that rCBF is increased in the epileptic temporal lobe several minutes before EEG seizure onset. Thus, rCBF changes observed on peri-ictal SPECT scan cannot be considered a mere consequence of EEG seizure activity but may rather reflect a change in neuronal activity precipitating the transition from the interictal to the ictal state.

Functional MR imaging of submandibular herniation of sublingual tissues through a gap of the mylohyoid muscle in two cases of submandibular "masses".

Except for neoplasms, in symptomatic patients with submandibular swellings, gaps of the mylohyoid muscle may be the cause of herniations of sublingual tissues, such as fat and/or the sublingual gland. In two patients with a submandibular swelling, MRI with standard sequences including contrast enhancement was performed to exclude a neoplastic lesion. In addition, we performed a trueFISP sequence during modified Valsalva's maneuver. In both patients, a neoplasm was excluded. Instead, the trueFISP sequence during the modified Valsalva's maneuver showed submandibular herniation of sublingual tissues. If MRI of the floor of the mouth does not show a neoplasm, an additional functional MR investigation should be performed. Gaps of the mylohyoid muscle can be the cause of herniating sublingual tissues (similar to plunging ranulas). During the modified Valsalva's maneuver, sublingual fat and/or gland can herniate and cause a symptomatic submandibular swelling. A coronal trueFISP sequence is particularly suited to demonstrate this.

Investigating quality of life and coping resources after laryngectomy.

Surgical procedures and in particular laryngectomy can become a life-saving treatment for patients with laryngeal or hypopharyngeal cancer, but can result in permanent damage. Clinical observation suggests that patients vary considerably in their ways of dealing with this new situation and in their ability to cope. The aim of our interdisciplinary group was to investigate the quality of life of laryngectomy patients and learn about their perceptions, situation and coping mechanisms. The development of an appropriate study design and a measurement strategy is presented. We investigated 29 laryngectomized patients who had joined the local self-help group. The patients were free from tumour disease and were mostly married with children, retired from work and had not graduated from high school. Assessment of the quality of life was performed with the European Organization for Research on Treatment of Cancer questionnaires QLQ-C30 and H+N35 and additional open questions. Analysis of the acquired data showed that family support was judged most important for overcoming the problems of disease and treatment. Deficits in this area were highly correlated with a low overall quality of life. Financial problems resulted because of the high percentage of retirement before or after therapy. We suggest that perioperative support taking these facts into consideration can result in an improved coping process. Further prospective studies are needed to reveal the effect of such measures.

[Bone neogenesis in a rare space-occupying lesion of the inner ear canal]. / Knochenneubildungen in einer seltenen Raumforderung des inneren Gehörgangs.

Hemangiomas of the skull base are rare neoplasms and are easily misdiagnosed as acoustic neuromas when occurring in the internal auditory canal. Among these tumors, ossifying hemangiomas are characterized histologically be newly formed bone tissue within their substance. We describe a 26-year old female patient who presented with left-sided sensorineural hearing loss and tinnitus. T2-weighted magnetic resonance imaging demonstrated a bright space-occupying lesion of the internal auditory canal with extension to the geniculate ganglion. Bony erosions of the internal auditory canal were proved by high-resolution computed tomography. A hemangioma was suspected preoperatively and was resected via a middle cranial fossa approach. Histologically, new bone formations were found in a cavernous hemangioma. In general, radiologic findings can suggest a hemangioma of the internal auditory canal and help to differentiate it from acoustic neuroma. Based on the histological findings of intratumoral bone formation, the hemangioma in our patient was classified as an ossifying hemangioma. However, reactive bone formation at the borders of a tumor in the internal auditory canal can also be mistaken as new intratumoral bone formation.